The Evolution of Minimally Invasive Donor Hepatectomy: Robotic vs Laparoscopic and Open Right Lobe Procurement. A Multicenter Study on 1194 Donor Hepatectomies

Abstract

Background: Laparoscopic and robotic Minimally invasive donor hepatectomies (MIDH) are increasingly performed, especially in Eastern countries. We conducted a retrospective, multicenter, propensity score-adjusted analysis on right lobe MIDH by comparing the robotic approach to the laparoscopic and open ones assessing feasibility, safety, and early outcomes. Methods: From January 2016 until December 2020, 1194 donors underwent right hepatectomy performed with a robotic (n=92), laparoscopic (n=306), and open approach (n=796) at six high volume centers. Propensity score matching (1:1:2) was performed to make donors comparable for sex, age, and body mass index (BMI), and recipients comparable for sex, age, BMI, liver disease, presence of HCC, MELD and graft-to-recipient-body weight ratio. Perioperative donor outcomes were analyzed, with complications classified according to Clavien-Dindo, and postoperative pain measured through a visual analog scale. Recipients' outcomes were also analyzed. Results: Ninety-two donors undergoing robotic surgery were matched and compared to 92 and 184 donors undergoing laparoscopic and open surgery. Conversions to open surgery occurred during 1 (1.1%) robotic and 2 (2.2%) laparoscopic procedures. Robotic procedures had a longer operative time than laparoscopic and open procedures (p < 0.001). The first graft warm ischemic time was also longer during robotic procedures. However, the robotic approach was associated with reduced donor blood losses (p<0.001). Postoperative mortality was nihil. No differences were observed in major complications (Clavien-Dindo ≥ IIIa). Donors undergoing robotic hepatectomy had less postoperative pain than those undergoing laparoscopic and open procedures (p<0.001). Fifty recipients of robotic-procured grafts were matched to 50 and 100 recipients of laparoscopic and open surgery procured grafts, respectively. There were no differences in terms of postoperative complicationns and 90 days mortality. After a mean follow-up of 18 months, recipients' survival was similar (p=0.455). Conclusions: In high volume centers, robotic right lobe procurement is a safe procedure for both donors and recipients. Despite an increased operative time, a robotic approach is associated with reduced intraoperative blood losses and postoperative pain, compared to the laparoscopic and open approaches. Recipients’ outcomes are independent of the surgical approach used for graft procurement.